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Based on record review and policy review, the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#12) of 35 Emergency Department (ED) records reviewed from 04/15/23 through 10/18/23. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). The hospital's average monthly ED census over the past six months was 3,809.

Findings included:

Review of the hospital's document titled, "Medical Staff Rules and Regulations," dated 06/14/23, showed that patients were to receive an appropriate MSE to determine if an EMC exists.

Review of the hospital's policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)," dated 10/04/22, showed that any person that presents to the ED requesting examination or treatment for a medical condition will receive a MSE to determine whether or not an EMC exists. The MSE is an ongoing process and the patient's medical record should reflect continued monitoring according to the patient's needs and must continue until the patient is stabilized, appropriately admitted, discharged, or transferred. An MSE consists of an assessment and ancillary tests based on the patient's chief complaint. This may include a history, physical exam, lab testing, electrocardiogram (EKG, test that records the electrical signal from the heart to check for different heart conditions), radiology procedures (a variety of medical imaging/x-ray techniques used to diagnose or treat diseases), or mental health screening evaluation.

Review of the hospital's undated policy titled, "Scope of Service," showed that reassessment of the patient is ongoing. Several methods may be used to reassess changes in the patient's condition including: variation to plan of care and/or problems/issues identified by individual team members.

Review of Patient #12's ED medical record, dated 07/10/23, showed:
- She was a 74 year-old female that presented to the ED for evaluation via private automobile.
- At 11:08 AM, her chief complaint was generalized back pain over the previous three days.
- She was dialysis (process that removes excess water and toxins from the blood when the kidneys can no longer perform these functions) dependent and did not receive dialysis on 07/10/23 due to back pain.
- At 6:01 PM, her temperature (T, degree of hotness or coldness of the body, normal is 98.6 F) was 98.5 F. This was the last time her temperature was assessed.
- At 9:21 PM, her respiratory rate (RR, the number of breaths per minute, normal range for adults at rest is 12 to 20) was 18. This was the last time her RR was assessed until Bi-level positive airway pressure (Bi-pap, a device that helps with breathing) was applied on 07/11/23 at 1:55 PM.
- At 11:42 PM, her Magnetic Resonance Imaging (MRI, test that uses a magnetic field and radio waves to create images of the organs and tissues within the body) showed early changes of osteomyelitis (infection of the bone) at the thoracic spine (middle portion of the spine).
- On 07/11/23 at 1:00 AM, Staff T, Registered Nurse (RN), applied oxygen via nasal cannula (NC, a lightweight tube with two prongs for insertion into the nostrils and delivery of oxygen) at three liters per minute (lpm, unit of measure). There was no physician order for the oxygen application. There was no nurse to physician communication regarding oxygen administration.
- At 1:02 AM, the patient was accepted for transfer to Hospital B (a nearby acute care hospital).
- At 1:55 AM, Staff T, RN, decreased her oxygen administration to 2 lpm via NC. There was no physician order for a change in the oxygen administration rate. There was no nurse to physician communication regarding oxygen administration.
- At 3:18 AM, the patient was accepted for transfer to Hospital C (a nearby acute care hospital).
- At 1:45 PM, Staff P, RN, increased the oxygen administration rate to 3 lpm via NC. There was no physician order for a change in the oxygen administration rate.
- At 1:51 PM, the patient complained of shortness of breath. Staff P, RN, notified Staff Q, Physician.
- At 1:55 PM, the patient was placed on Bi-Pap.
- At 2:25 PM, the patient was intubated (a process where a healthcare provider inserts a tube through a person's mouth or nose down to their windpipe when a person is not breathing on their own) and a code blue (emergency situation where a patient's heart or breathing has stopped, and staff quickly respond to attempt to restore the heartbeat and/or breathing) was initiated.
- At 2:57 PM, Patient #12 was pronounced dead.

Please refer to 2406 for further details

Based on interview, record review and policy review, the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#12) of 35 Emergency Department (ED) records reviewed from 04/15/23 through 10/18/23. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). The hospital's average monthly ED census over the past six months was 3,809.

Findings included:

Review of the hospital's document titled, "Medical Staff Rules and Regulations," dated 06/14/23, showed that patients were to receive an appropriate MSE to determine if an EMC exists.

Review of the hospital's policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)," dated 10/04/22, showed that any person that presents to the ED requesting examination or treatment for a medical condition will receive a MSE to determine whether or not an EMC exists. The MSE is an ongoing process and the patient's medical record should reflect continued monitoring according to the patient's needs and must continue until the patient is stabilized, appropriately admitted, discharged, or transferred. An MSE consists of an assessment and ancillary tests based on the patient's chief complaint. This may include a history, physical exam, lab testing, electrocardiogram (EKG, test that records the electrical signal from the heart to check for different heart conditions), radiology procedures (a variety of medical imaging/x-ray techniques used to diagnose or treat diseases), or mental health screening evaluation.

Review of the hospital's undated policy titled, "Scope of Service," showed that reassessment of the patient is ongoing. Several methods may be used to reassess changes in the patient's condition including: variation to plan of care and/or problems/issues identified by individual team members.

Review of Patient #12's ED medical record, dated 07/10/23, showed:
- She was a 74 year-old female that presented to the ED for evaluation via private automobile.
- At 11:08 AM, her chief complaint was generalized back pain over the previous three days.
- Her past medical history included end-stage renal disease (ESRD, the final stage of kidney disease, where the kidneys can no longer function on their own) and was dialysis (process that removes excess water and toxins from the blood when the kidneys can no longer perform these functions) dependent, coronary artery disease (CAD, the narrowing or blockage of the coronary arteries usually caused by the buildup of cholesterol and fatty deposits on the inner walls of the arteries), chronic obstructive pulmonary disease (COPD, a lung disease that prevents normal airflow and breathing), Insulin Dependent Diabetes Type II (IDDM a form of diabetes in which patients have little or no ability to produce insulin [a chemical that allows cells to absorb sugar from the blood]), congestive heart failure (CHF, a weakness of the heart that causes it to not pump blood like it should leading to a buildup of fluid in the lungs and surrounding tissues) and sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts).
- She did not receive dialysis on 07/10/23 as schedule.
- At 6:01 PM, her temperature (T, degree of hotness or coldness of the body, normal is 98.6 F) was 98.5 F. This was the last time her temperature was assessed.
- At 9:21 PM, her respiratory rate (RR, the number of breaths per minute, normal range for adults at rest is 12 to 20) was 18. This was the last time her RR was assessed until Bi-level positive airway pressure (Bi-pap, a device that helps with breathing) was applied on 07/11/23 at 1:55 PM.
- At 11:42 PM, her Magnetic Resonance Imaging (MRI, test that uses a magnet field and radio waves to create images of the organs and tissues within the body) showed early changes of osteomyelitis (infection of the bone) of her thoracic spine (middle portion of the spine).
- On 07/11/23 at 1:00 AM, Staff T, RN, applied oxygen via nasal cannula (NC, a lightweight tube with two prongs for insertion into the nostrils and delivery of oxygen) at three liters per minute (lpm, unit of measure). There was no provider order for the oxygen application. There was no nurse to provider communication regarding oxygen administration.
- At 1:02 AM, the patient was accepted for transfer to Hospital B (a nearby acute care hospital).
- At 1:55 AM, Staff T, RN, decreased her oxygen administration to two lpm via NC. There was no provider order for a change in the oxygen administration rate. There was no nurse to provider communication regarding oxygen administration.
- At 3:18 AM, the patient was accepted for transfer to Hospital C (a nearby acute care hospital).
- At 1:45 PM, Staff P, RN, increased the oxygen administration rate to three lpm via NC. There was no provider order for a change in the oxygen administration rate. There was no nurse to provider communication regarding oxygen administration.
- At 1:51 PM, the patient complained of shortness of breath. Staff P, RN, notified Staff Q, Physician.
- At 1:55 PM, the patient was placed on Bi-pap.
- At 2:25 PM, the patient was intubated (a process where a healthcare provider inserts a tube through a person's mouth or nose down to their windpipe when a person is not breathing on their own) and a code blue (emergency situation where a patient's heart or breathing has stopped, and staff quickly respond to attempt to restore the heartbeat and/or breathing) was initiated.
- At 2:35 PM, her chest x-ray (test that creates pictures of the structures inside the body-particularly bones) showed mild vascular congestion (the swelling of bodily tissue caused by increased vascular (relating to or containing blood vessels) blood flow with subtle developing alveolar infiltrates (abnormal substances that buildup up in the alveolar spaces [microscopic balloon-shaped structures located at the bottom of the lungs]) and mild cardiomegaly (an enlarged heart).
- At 2:57 PM, Patient #12 was pronounced dead.

Review of ED Physician Note, dated 07/11/23, at 3:08 PM, showed he was called to the room by the RN. Patient had rapid onset of difficulty breathing. Her oxygen saturation (measure of how much oxygen is in blood) was normal. Auscultation of lungs showed crackles and she had increased work of breathing. She had missed dialysis yesterday. Orders were placed for an EKG, chest x-ray, bi-pap and arterial blood gas (ABG, a blood test that measures the amount of oxygen and carbon dioxide in the blood). When the technician attempted to obtain the EKG the patient developed bradycardia (slow heart rate). Staff L, Physician, and Staff Q, Physician, responded and the patient quickly lost her pulses. Cardio-Pulmonary resuscitation (CPR, emergency life-saving procedure performed when a person's breathing or heartbeat has stopped) was initiated. Mild to moderate fluid overload was noted clinically. Family arrived to bedside and requested resuscitation efforts to stop. The patient was pronounced dead on 07/11/23 at 2:57 PM.
There was no documentation in the medical record that any additional patient physical assessments were performed after her initial triage assessment on 07/10/23 at 11:30 AM.

During an interview on 10/23/23 at 12:10 PM, Staff Q, Physician, stated that he did not know if an order was needed to provide oxygen to a patient. He was consulted by the PA due to physical tenderness and he ordered an MRI. The MRI results were not available before he signed out for the day. The next day he was called to the room because the patient was having shortness of breath. He did not recognize her from the day before and she appeared short of breath. He then planned to place orders relating to her shortness of breath and updated Staff L, Physician. Staff L took over care of the patient. The patient then quickly decompensated and a code blue was called. The physicians could not understand what had caused the patient to require resuscitation. Because Patient #12 missed dialysis, further assessment and evaluation would be have been prudent with the long ED wait. This is a "systemic failure." Receiving hospitals do not communicate when a bed will be available and patients "fall off of the radar." Hospitalist could be consulted for assistance with patient management for patients with long ED waits. Consults were difficult with transfers because it may be a "waste of the hospitalist's time and busy work," if the patient was transferred quickly after the consult was placed. This results in a loss of "political capital" with the hospitalists. Patient #12's hospitalist consult would have been dependent upon the receiving hospitals communication regarding bed availability timing. A new need for oxygen would "obviously" have been an indication for further evaluation and assessment. When the patient "falls off of the radar," there are not additional provider assessments or evaluations.

During an interview on 10/19/23 at 4:30 PM, Staff R, Physician Assistant (PA), stated that Patient #12 ambulated into the ED and was stable. No symptoms of shortness of breath, tachypnea (rapid shallow breathing), tachycardia (fast heart rate) or hypoxia (not enough oxygen reaching the cells and tissues in the body) were present on 07/10/23. He stated that the use of oxygen overnight may have been an indication for additional evaluation.

During an interview on 10/18/23 at 3:30 PM, Staff L, Physician, stated that the need for dialysis would be based on an assessment for electrolytes (minerals in the blood and other body fluids that carry an electric charge) changes. Respiratory symptoms that required Bi-Pap support would be an indication for urgent dialysis. He stated that a hospitalist may be consulted to assist with the management of medical conditions for patients with long wait times in the ED.

During an interview on 10/18/23 at 2:00 PM, Staff C, ED Manager, stated that when a patient had a long wait in the ED for transport or for a bed, a hospitalist may be consulted to manage medical conditions. She stated that there was a "potential need" for further evaluation of Patient #12's need for dialysis while waiting for transport to a higher level of care.

During an interview on 10/18/23 at 2:05 PM, Staff N, ED Director, stated that he was notified that Hospital B did not have a bed available for Patient #12. He then contacted Hospital C and received an acceptance of transfer. The delay in transfer was due to there were no current beds available at Hospital C. Staff N, stated that a hospitalist may be consulted to assist in the management of patients with long wait times in the ED to manage medical conditions. He stated that a decision to proceed with dialysis for Patient #12 would have been based on her symptoms such as laboratory values, respiratory status and EKG changes. His expectation was that a dialysis patient with a long wait in the ED would have a daily complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection) and comprehensive metabolic panel (CMP, a blood test performed to determine a variety of diseases and conditions). If the patient developed respiratory symptoms he would expect an EKG and Chest X-ray be completed, to rule out a "pulmonary edema (an abnormal buildup of fluid in the lungs)." He stated that a new need for oxygen at a rate of two to three lpm overnight would not prompt an emergent nephrology (the branch of medicine that deals with the kidneys, especially their functions or diseases) consult, but a consult would be indicated in the morning, during the waking hours. He stated that, "nephrology should have been called in the morning due to the need for oxygen administration overnight" for Patient #12. There should "definitely" have been an assessment including a chest x-ray and blood work in response to the new need for oxygen administration.

During an interview on 10/23/23 at 4:30 PM, Staff T, RN, stated that there were protocols for administering oxygen to a patient. He stated that it was easier to get a verbal order for oxygen, because the providers were available. He vaguely remembered administering oxygen to Patient #12 but did not remember the reason why. He could not find a written order for the oxygen. Any change in condition was to be communicated to the physician and an oxygen requirement was a change in condition. Staff T did not perform a head to toe assessment for Patient #12 while he was responsible for her care.

During an interview on 10/23/23 at 11:00 AM, Staff S, RN, stated that a nurse could apply oxygen before receiving an order, but the provider would then need to be notified of the change in condition. Providers were to be notified with any change in condition. A new need for oxygen would have been a "definite concern." She stated that "we must be mindful" throughout the entire patient's ED stay. Physical assessments should have been performed every shift.

During an interview on 10/18/23 at 2:50 PM, Staff M, RN, stated that it was necessary to communicate with the physician when oxygen was applied. He stated that Patient #12 did not require oxygen administration during the day on 07/10/23.

During an interview on 10/18/23 at 3:10 PM, Staff P, RN, stated that nurses were to perform continued assessments on patients and communicate any change in condition to the provider. She stated that the application or change of flow rate of oxygen needed to be communicated to the provider. She stated that Patient #12's transfer delay was related to Hospital C not having a bed available.

During an interview on 10/18/23 at 1:30 PM, Staff O, RN, stated that the delay in transfer was related to there not being a bed at the receiving Hospital C. She stated that a physician order was necessary to initiate or change flow rates for oxygen administration.

During an interview on 10/18/23 at 4:00, Staff A, Regulatory Affairs Director, stated that a provider order was necessary to apply or change the rate of oxygen.

Based on interview, record review and policy review, the hospital failed to provide within its capability and capacity, ongoing assessment, re-assessment and stabilization for one patient (#12), whom developed hypoxia (not enough oxygen reaching the cells and tissues in the body) while waiting for transport to a higher level of care. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. The hospital's average monthly ED census over the past six months was 3,809.

Findings included:

Review of the hospital's undated policy titled, "Scope of Service," showed that reassessment of the patient is ongoing. Several methods may be used to reassess changes in the patient's condition including: variation to plan of care and/or problems/issues identified by individual team members.

Review of the hospital's policy titled, "EMTALA," dated 10/04/22, showed that any person that presents to the ED requesting examination or treatment for a medical condition will receive a MSE to determine whether or not an EMC exists. The MSE is an ongoing process and the patient's medical record should reflect continued monitoring according to the patient's needs and must continue until the patient is stabilized, appropriately admitted, discharged, or transferred.

Review of Patient #12's ED medical record, dated 07/10/23, showed:
- She was a 74 year-old female that presented to the ED for evaluation via private automobile.
- At 11:08 AM, her chief complaint was generalized back pain over the previous three days.
- She was dialysis (process that removes excess water and toxins from the blood when the kidneys can no longer perform these functions) dependent and did not receive dialysis on 07/10/23 due to back pain.
- At 9:21 PM, her respiratory rate (RR, the number of breaths per minute, normal range for adults at rest is 12 to 20) was 18. This was the last time her RR was assessed until Bi-level positive airway pressure (Bi-pap, a device that helps with breathing) was applied on 07/11/23 at 1:55 PM.
- On 07/11/23 at 1:00 AM, Staff T, Registered Nurse (RN), applied oxygen via nasal cannula (NC, a lightweight tube with two prongs for insertion into the nostrils and delivery of oxygen) at three liters per minute (lpm, unit of measure). There was no nurse to physician communication regarding oxygen administration.
- At 1:55 AM, Staff T, RN, decreased her oxygen administration to 2 lpm via NC. There was no nurse to physician communication regarding oxygen administration.
- At 3:18 AM, the patient was accepted for transfer to Hospital C (a nearby acute care hospital).
- At 1:45 PM, Staff P, RN, increased the oxygen administration rate to 3 lpm via NC. There was no nurse to physician communication regarding oxygen administration.
- At 1:51 PM, the patient complained of shortness of breath. Staff P, RN, notified Staff Q, Physician.
- At 1:55 PM, the patient was placed on Bi-Pap.
- At 2:25 PM, the patient was intubated (a process where a healthcare provider inserts a tube through a person's mouth or nose down to their windpipe when a person is not breathing on their own) and a code blue (emergency situation where a patient's heart or breathing has stopped, and staff quickly respond to attempt to restore the heartbeat and/or breathing) was initiated.
- At 2:57 PM, Patient #12 was pronounced dead.

During an interview on 10/18/23 at 2:50 PM, Staff M, RN, stated that it was necessary to communicate with the physician when oxygen was applied. He stated that Patient #12 did not require oxygen administration during the day on 07/10/23.

During an interview on 10/18/23 at 3:10 PM, Staff P, RN, stated that nurses were to perform continued assessments on patients and communicate any change in condition to the provider. She stated that the application or change of flow rate of oxygen needed to be communicated to the provider.

During an interview on 10/19/23 at 4:30 PM, Staff R, Physician Assistant (PA, a type of mid-level health care provider that can diagnose illnesses, develop and manage treatment plans, prescribe medications, and may serve as a principal healthcare provider), stated that Patient #12 walked into the ED and was stable. No symptoms of shortness of breath, tachypnea (rapid shallow breathing), tachycardia (fast heart rate) or hypoxia were present on 07/10/23. He stated that the use of oxygen overnight may have been an indication for additional evaluation.

During an interview on 10/23/23 at 12:10 PM, Staff Q, Physician, stated that he was called to the room because Patient #12 was having shortness of breath. She appeared short of breath, he planned to place orders relating to her shortness of breath and updated Staff L, Physician. Staff L took over care of the patient. The patient quickly decompensated and a code blue was called. He was not sure what had caused the patient to require resuscitation. Because Patient #12 missed dialysis, further assessment and evaluation would have been prudent with the long ED wait. This was a "systemic failure." Receiving hospitals do not communicate when a bed will be available and patients "fall off of the radar." Hospitalist (physician whose primary professional focus is the general medical care of hospitalized patients) could be consulted for assistance with patient management for patients with long ED waits. Consults were difficult with transfers because it may be a "waste of the hospitalist's time and busy work," if the patient is transferred quickly after the consult is placed. This results in a loss of "political capital" with the hospitalists. Patient #12's hospitalist consult would have been dependent upon the receiving hospitals communication regarding bed availability timing. A new need for oxygen would "obviously" have been an indication for further evaluation and assessment. When the patient "falls off of the radar," there are not additional provider assessments or evaluations.

During an interview on 10/18/23 at 2:05 PM, Staff N, ED Director, stated that if the patient developed respiratory symptoms he would expect an EKG and Chest X-ray (test that creates pictures of the structures inside the body-particularly bones) to be completed, to rule out "pulmonary edema (an abnormal buildup of fluid in the lungs)." He stated that a new need for oxygen at a rate of two to three lpm overnight would not prompt an emergent nephrology (the branch of medicine that deals with the kidneys, especially their functions or diseases) consult, but a consult would be indicated in the morning, during the waking hours. He stated that, "nephrology should have been called in the morning due to the need for oxygen administration overnight for Patient #12. There should "definitely" have been an assessment including a chest x-ray and blood work in response to the new need for oxygen administration.

During an interview on 10/18/23 at 3:30 PM, Staff L, Physician, stated that the need for dialysis would be based on an assessment for electrolyte (minerals in the blood and other body fluids that carry an electric charge) changes. Respiratory symptoms that required Bi-Pap support would be an indication for urgent dialysis. He stated that a hospitalist may be consulted to assist with the management of medical conditions for patients with long wait times in the ED.

During an interview on 10/23/23 at 11:00 AM, Staff S, RN, stated that a nurse could apply oxygen before receiving an order, but the provider would then need to be notified of the change in condition. Providers were to be notified with any change in condition. A new need for oxygen would have been a "definite concern." She stated that "we must be mindful" throughout the entire patient's ED stay.

During an interview on 10/23/23 at 4:30 PM, Staff T, RN, stated that there were protocols for administering oxygen to a patient. He stated that it was easier to get a verbal order for oxygen, because the providers were available. He vaguely remembered administering oxygen to Patient #12 but did not remember the reason why. He could not find a written order for the oxygen. Any change in condition was to be communicated to the physician and an oxygen requirement was a change in condition.

Please refer to 2406 for further details